1. Manatee ER Diversion (Fusco) 1 Manatee County Rural Healthcare Services ER Diversion Program

2. Manatee ER Diversion (Fusco) 2 Recognition of the problem Data from HMOs and Medipass (Phytrust/Access) showed increased ER utilization by our patients during reduced hours of staffing. Emergency room data showed significant number of non-emergent ER visits. Hospital wanted to reduce the number of indigent non-emergent visits. Some of the patients did not have a medical home, others were patients of MCRHS or other local physicians but the need for care arrived at a time when office access was not available. The issue is ACCESS!

3. Manatee ER Diversion (Fusco) 3 The Cost of Avoidable ER Visits At least a third of ER visits are “Avoidable”, meaning non urgent and therefore treatable in a primary care setting ER charges for minor, non-urgent problems may be 2 to 5 times higher than typical private physician visits At least $18 billion dollars are wasted annually for avoidable ER visits nationally It is estimated that $ 1.1 billion dollars are wasted on avoidable ER visits in Florida Figures are based on relevant literature, which assumes 35% of ER visits are “Avoidable”. The formula calculates the average expenditure for ER visits by region subtracted by the average cost of a CHC medical visit for each state.

4. Manatee ER Diversion (Fusco) 4 ER Wait Times and Visits on the Rise 44.9% of U.S. hospitals experienced ER crowding sometime between 2003-2004 ER wait times are rising and much higher than in primary care settings such as health centers Between 1999 and 2005 Florida had an average of 380 ER visits per 1,000 population compared with 376 nationally Florida ER Visits Per 1,000 19992000 2001 2002 20032004 2005 Florida 363 376 359 397392 390 388

5. Manatee ER Diversion (Fusco) 5 Factors Contributing to Rise in ER Use Increase in elderly and chronically ill Overworked primary care physicians Lack of primary care beyond “normal” business hours Patient preferences

6. Manatee ER Diversion (Fusco) 6 Who Accounts for the Rise in ER Visits? Privately insured are major driver in increased ER visits Medicaid beneficiaries have twice the ER visit rates as uninsured and four times the rate of the privately insured Though the uninsured are not driving increased ER use, those who rely on the ER may do so because they lack a primary care provider Medicaid beneficiaries and the uninsured account for more “Avoidable” ER visits

7. Manatee ER Diversion (Fusco) 7 Potential Savings to Medicaid Creating programs that direct Medicaid patients to primary care sources would result in more efficient health care delivery system, and would produce greater cost savings than Medicaid enrollment reductions. By providing primary care to Medicaid beneficiaries at health centers instead of ERs, it is estimated that health centers could save Medicaid Approximately $4 billion (annually) nationally Approximately $ 233.5 million (annually) in Florida This is based on the fact that $18.4 billion is wasted annually on ER visits in the U.S. ($1.1 Billion in Florida) and Medicaid patients make up 22% of all ER visits.

8. Manatee ER Diversion (Fusco) 8 Plan The initial thoughts were to establish an FQHC site in the hospital and divert the non-emergent patients who came to the ER right there. The ER doctors realized that they would lose significant income if the non-emergency indigent and paying patients were both diverted from the ER. MCRHS then decided to extend the hours of service at two primary care sites, the Lawton Chiles Children’s Healthcare Center and its’ Acute Care location at the East Manatee Healthcare Center.

9. Manatee ER Diversion (Fusco) 9 Plan (continued) The Lawton Chiles Center was planned to be open from 8am to 9pm Monday through Friday extending access by 20 hours per week to see children. The East Manatee Acute care location was planned to be open 8am to 9pm Monday through Saturday and 12 noon to 9pm on Sunday extending hours 40 hours per week to see adults and children. Hospital emergency room unassigned non-emergent patients would be triaged and given the option to receive care at one of our ER diversion sites.

10. Manatee ER Diversion (Fusco) 10 Plan (continued) Hospital emergency room unassigned patients who were treated in the ER and released would be referred to an MCRHS primary care site for follow up care. MCRHS applied for a State LIP grant through the Invitation To Negotiate (ITN) Process.

11. Manatee ER Diversion (Fusco) 11 Key Partners and Funding Coordination and communication with the hospital emergency room managers and physicians is essential. The LIP grant funding was essential to cover start up and operational costs. Service is the key to attracting paying patients (you are competing for the paying patient). County indigent care safety net funding.

12. Manatee ER Diversion (Fusco) 12 Facilities and Staffing Existing facilities were used and the hours of service were extended to improve access. For the extended hours Sunday through Friday the staffing consists of a primary care provider (physician or midlevel), 1 front desk clerk, 1 CNA, 1 LPN and a medical records person. On Saturday mornings an additional Provider and CNA are added.

13. Manatee ER Diversion (Fusco) 13 Data and Information Management Patients are entered into the Medical Manager system and the EMR. A comma extension on the procedure code field and a specific location code are used for ER diversion visit identifiers. The 99050 and 99051 CPT codes for after hours care are paid by some providers. Clinical and demographic reports can be run from the EMR and Medical Manager. Patients can be tracked clinically through the EMR.

14. Manatee ER Diversion (Fusco) 14 Obstacles and barriers and how they were overcome Start up funds, ITN grant. Acquiring local match funds for the ITN grant. Attracting insured and paying patients. Staffing.

15. Manatee ER Diversion (Fusco) 15 Users by Payer Payer Source Self Pay MedicaidMedicarePrivatePublicTotal Feb 05 - June 05 2,0041,36310626973,749 July 05 - June 06 5,8333,4822347991010,358 July 06 - June 07 6,1903,352266942610,756 July 07 - June 08 8,1563,8475061,5731414,099 TOTALS22,18312,0441,1123,5833738,962

16. Manatee ER Diversion (Fusco) 16 EncountersUsersEncounters Per User Feb 05 - June 05 4,5653,7491.2 July 05 - June 06 15,25110,3581.5 July 06 - June 07 15,66410,7561.5 July 07 - June 08 20,58914,0991.5 TOTALS56,07438,9621.4 Encounters per User

17. Manatee ER Diversion (Fusco) 17 Impact on ER Manatee Memorial Hospital ER Levels by Payor Sum of QtyVisits CPT4 Desc2004200520062007 Level 1 Total 2,868 190246339 Level 2 Total 8,680 6,911 6,8036,967 Level 3 Total 15,660 14,26912,41113,333 Level 4 Total 24,600 22,43119,88918,937 Level 5 Total 5,799 8,56810,84110,981 Level 6 Total 485 653351288 Triage Only Total 515 2,4242,5151,274 Grand Total 58,607 55,44653,05652,119

18. Manatee ER Diversion (Fusco) 18 Medicaid Savings ER Medicaid MCRHS Medicaid Users12,044 Encts. Per User1.4 Encounters16,862 Cost Per Enct.$452$114 Medicaid Savings Total Cost$7,621,443$1,922,222$5,699,221

19. Manatee ER Diversion (Fusco) 19

20. Manatee ER Diversion (Fusco) 20

21. Manatee ER Diversion (Fusco) 21 1. Central referral and scheduling directly from the ER. 2. Addition of Sarasota and Arcadia sites. 07 – 08 Enhancements

22. Manatee ER Diversion (Fusco) 22 For more information contact: Ray Fusco, Chief Operating Officer rfusco@mrhcs.org